Care should be aligned with components of the chromic care model (CCM) to ensure productive interactions between a prepared proactive practice team and an informed activated patient

56
American Diabetes Association, 2016

A

When feasible, care systems should support team-based care, community involvement, patient registries and embedded decision-support tools to meet patient needs

56
American Diabetes Association, 2016

B

Treatment decisions should be timely, and based on evidence-based guidelines that are tailored to individual patient preferences, prognoses and comorbidities

56
American Diabetes Association, 2016

B

*Refer to Summary, explanation and source of recommendations for an explanation of the level of evidence and grade of evidence

Clinical context

The goal of a structured care program is to increase the quality of life for people with diabetes. Structured care means having all the necessary aspects of the required care in place.

The structure of each diabetes care program will vary depending on the local circumstances and the needs of the patient. There is good evidence to support patient access to a variety of healthcare providers.17

Access to, and care delivery by, different healthcare providers allows the patient to benefit from a broad perspective on their health and wellbeing. There are some team roles that fit into most patients’ programs, but whatever the composition of the team, care needs to be organised and delivered systematically.

Multidisciplinary care (Figure 2) also covers gaps in care that may be apparent to one healthcare provider, but go unnoticed by another. For example, recognising a patient’s social difficulties may be detected during an educator evaluation or by a practice nurse rather than during a routine medical consultation.

Figure 2. Potential members of the multidisciplinary diabetes care team

Registered and practice nurses within a general practice can provide an administrative and a clinical role. Practice nurses often manage the diabetes register, structured care-and-recall system, as well as provide a clinical assessment before the GP sees the patient. Practice nurses have an important role in team-based care processes, including motivational interviewing, education activities and support for lifestyle modification. These can be facilitated and enabled upon GP assessment and recommendation. This enables healthcare efficiency and allows the GP to focus on any identified problems. Practice nurses can also act as practice liaison, and facilitate rapid access to GP care in the event of a clinical problem.

ABORIGINAL AND TORRES STRAIT ISLANDER POINT

Involvement of an Aboriginal health worker, or an Aboriginal liaison officer, or Indigenous outreach worker or care coordinator is essential in
the care of Aboriginal and Torres Strait Islander peoples.